Prevalence of Musculoskeletal, Neurological and Physical Disorder After COVID-19 in Saudi Arabia: A Cross Sectional Study

Introduction

The global pandemic of coronavirus disease 2019, commonly known as COVID-19, continues to spread. The clinical presentations of COVID-19 varied from asymptomatic to severe critical condition. Although COVID-19 is a respiratory disease, numerous investigations documented extrapulmonary signs and symptoms. Musculoskeletal complaints, myopathies, and neuropathies are common post COVID-19 clinical presentations.¹ Patients with multiple manifestations ranged from asymptomatic or moderate (70% of cases) to severe or possibly fatal (30% of cases).² Although the severity of the symptoms varied with age and medical history of chronic diseases (comorbidity, such as chronic cardiac disease, lung disease, diabetes, chronic renal disease, and cancer). The most common symptoms included fever, cough, shortness of breath, fatigue, myalgia, and gastrointestinal symptoms. These symptoms may last for a long time even after recovery.^3,4 Symptoms might linger for weeks or months, and some people never return to their previous level of health.⁴

In this regard, the emergence of COVID-19 has compelled governments worldwide to take different steps and decisions to prevent the pandemic from spreading quickly.⁵ Social distancing, capacity constraints in public venues and private houses, isolation, quarantine, and curfew enforcement were among the preventative measures employed.⁶ Saudi Arabia have been eager to apply social distancing and quarantine in order to avoid illness spread.

As a result, those preventative measures may have physical, emotional, and psychological impacts on people’s life. According to Mattioli et al., precautionary measures had a negative impact on individuals, the society, and the economy which resulted in (a) an increase of community anxiety and tension, (b) an economic decline, (c) decreased outdoor exercises and overall physical activity (PA), (d) and development of both stress and depression, which can lead to unhealthy dietary habits.^5,7

Although there are numerous examples of long-term problems after COVID-19 infection, there is lack of research to support. There was a loss in patients’ functional capacity, which was correlated to the reduction in numbers of health-related quality-of-life indices. There was also evidence of cognitive problems, such as confusion and memory loss. High blood pressure, obesity, and mental health disorders were identified as risk factors for the persistence of these symptoms.⁶ The importance of physical therapy in dealing with these issues should not be overstated. It is crucial to begin studying the long-term effects of COVID-19 infection.⁷ To our knowledge, there is a lack of information and no previous study on the correlation between the prevalence of neurological, musculoskeletal, and physical disorders and COVID-19 in KSA. So, we aimed in this study to determine the long-term impacts of COVID-19 on physical health, daily life activities, musculoskeletal and neurological functions in the KSA.

Methods

Sampling

The required sample size was calculated using Raosoft sample size calculator (Raosoft, Inc., Seattle, WA, USA), with a confidence interval of 99%, a response rate of 70%, and a margin error of 5%. The sample size was 1200 participants. A two-stage sampling approach was employed to select participants, with a random sampling of participants from different district followed by a random selection of participants from those districts. During the first sampling stage, random selection was conducted on a list of patients in the hospital database and 520 patients returned the questionnaire. 21 respondents were excluded because of missing data. Finally, 499 respondents were included in this study (Figure 1).

Figure 1. Flow diagram of sample selection.

Results

A total of 499 responses were presented and analyzed. Duration of persistent symptoms was set from one month to three months. Females made up nearly 70% of the samples, with the majority aged under 45 years. Among the participants, 245 (49.1%) were employed, including 60 (24.9%) civilian workers, 38 (15.8%) military members, 37 (15.4%) medical workers, and 254 (50.9%) were unemployed. Out of 499 respondents, 275 (55.1%) of the participants reported that they had practice of exercising before COVID-19 infection (mostly walking, 67.6%), while 224 (44.9%) had not participated in any type of exercises before COVID-19 infection. 394 (69.9%) females were affected, while 150 (30.1%) men were affected. Most of them (420 = 84.2%) were under 45 years old, and 79 (15.8%) were over 45 years old. 405 (81.2%) of the participants came from the Western region of Saudi Arabia. About 118 (23.6%) of the participants had chronic diseases, including respiratory disease (42 = 8.4%), diabetes mellitus (DM) (41 = 8.2%), hypertension (HT) (26 = 5.2%), cancer (5 = 1.0%), and cardiac disorders (3 = 0.6%). 381 (76.4%) participants were free of chronic diseases (Table 1).

In this study, headache (63.1%) was the most reported symptom after COVID-19 infection, followed by muscle ache or weakness (62.3%), vertigo (25%), concentration problems (21.8%), breathing troubles (20.4%), and loss of balance (19.4%). On the other hand, five cases of seizure (1%, four cases of intermittent seizure and one case of continuous seizure), and three cases of Guillain-Barre Syndrome (0.6%) have been documented and were the least common symptoms. Many participants were suffering from more than one persistent symptoms after COVID-19 infection, so the percentages were more than 100 percent (Table 2).

Certain symptoms, such as breathing problems and muscle discomfort or weakness persisted after COVID-19 infection had cleared up in a median duration of 30 days and an interquartile range of 45 days. Regarding muscle pain, back muscles were the most affected (122 = 24.4%), followed by lower limb muscles (77 = 15.4%), neck muscles (30 = 6.0%), pelvic muscles (19 = 3.8%), and upper limb muscles (17 = 3.4%) (Table 3).

Many participants in this study showed a link between reported symptoms and certain physical activity performance after COVID-19 infection. Gender and physical activity performance were shown to have a significant relationship in 146 (29.3%) of participants (p = .001). There were 118 (80.8%) females and 28 (19.2%) males. There was a significant link between persistent symptoms’ impact on physical activity performance and respiratory disease (p = 0.017), with 330 (93.5) patients without respiratory diseases recording no persistent symptoms on physical performance and 127 (87.0) patients with respiratory diseases recording persistent symptoms on physical performance. No significant association were found between physical activity performance after COVID-19 infection and the habit of exercising before COVID-19 infection. 80 (54.8%) of the subjects had habit of exercising before the infection, whereas 66 (45.2%) had not. Furthermore, 195 (55.2%) had habit of exercising before the infection, which had no effect on their physical activity performances, while 158 (44.8%) had no habit of exercising before the infection and had no complaints of physical performance performances.

A majority of 353 participants (70.7%) do not record any association between persistent symptoms and certain physical activity performance, 231(65.4%) were females and 122 (34.6%) were males. Patients without hypertension had the highest comorbidity value of 337 (95.5%), followed by those without respiratory diseases (330 = 93.5%), non-diabetic patients (323 = 91.5%), diabetic patients (30 = 8.5%), patients with respiratory diseases (23 = 6.3%), and patients with hypertension (16 = 4.5%) (Table 4).

Additionally, participants who recorded persistent symptoms were asked to specify the frequency of symptoms. However, significant association was found between gender and frequency of symptoms (from 58 participants who recorded symptoms to be always persisting); females (47 = 81%) recorded higher frequency than males (11 = 19%), as shown in Table 5. Another significant association was discovered between respiratory disorders before infection and the prevalence of persistent symptoms, (p < 0.001). The findings showed that 280 (98.2%) of those who had no respiratory disorders before COVID-19 infections had no symptoms after the infection, while 5 (1.8%) of those who had respiratory diseases before COVID-19 infection had no symptoms after the infection.

Table 5 provided more information about the participants who reported the presence of symptoms occasionally while performing everyday activities, 133 (85.3%) without respiratory diseases and 23 (14.7%) with respiratory diseases. Other demographic data and comorbidities failed to reveal any statistically significant association between the impact and physical activity (age, practicing exercises before infection).

Discussion

To our knowledge, this is the first study to evaluate the prevalence of musculoskeletal, neurological and physical disorder after COVID-19 in the KSA adult population and their relationship with physical activities. The purpose of the current study is to determine the prevalence of musculoskeletal, neurological, and physical health problems after COVID-19 infection, as well as how it affects the capability of daily life activities. Overall, this study found that musculoskeletal, neurological, and physical activity were negatively affected after COVID-19 infection. This study involved 499 participants. According to demographic data, the percentage of women infected COVID-19 (349 = 69.9%) was higher than that of men (150 = 30.1%). This is different from a previous study in the KSA, in which the authors reported a higher prevalence among males than females. This is agreed with the percentage of total daily cases reported in the same study, in which male was decreased by 18.0%, compared to a 150% increase in females.⁸ Participants under 45 years old were also more impacted (420 = 84.2%) than those over 45 years old (79 = 15.8%), which matched the findings of a pervious study (Alyami et al., 2020) that COVID-19 was more prevalent in adults than in children and elderlies. Our findings revealed that 275 persons (55.1%) had practiced physical activities before COVID-19 infection, which is higher than that reported by the General Authority for Statistics in 2019.⁹ This could be due to the larger sample size and increased awareness of the health benefits of physical activity among the Saudi population.

Low back pain was the most frequently recorded symptom among the participants after COVID-19 infection. The results are similar to those reported in a cross-sectional study conducted in Riyadh, Saudi Arabia with a sample of 463 participants. The reason for this is most likely owing to the detrimental impacts of quarantine for most nations during the Corona epidemic, as stated in a cross-sectional study done in Riyadh, Saudi Arabia with a sample size of 463 people. Sitting for long periods during quarantine may reduce lumbar muscle activity, which overloads the body’s passive tissues, such as intervertebral discs and ligaments.¹⁰ Furthermore, pain in the lower limb muscles was identified as the second most prevalent muscle pain in this study, which coincided with the previous study and could be due to the same reasons that produce low back pain.¹⁰ The presence of musculoskeletal manifestations in the current study findings could be explained by the fact that the Saudi Arabian government’s quarantine decree, as well as its strict implementation to ensure the preservation of public health for all people and the commitment of all people to it, which influenced the population’s lifestyle in terms of physical activity, dietary habits, and mental health. This phenomenon contributed to musculoskeletal problems, supported by multiple studies showing that physical activity rates were dramatically reduced, and food habits were negatively impacted following the lockdown.¹¹ The high prevalence of muscle discomfort, particularly low back pain and other musculoskeletal complaints, may be explained by long hours of screen usage for work and education.

In this study, the impacts of COVID-19 on physical activity were recorded, and certain parameters such as gender and respiratory disease were found to be significantly related. The proportion of females who reported an impact on physical activity was 33.8%, compared to 18.67% of males (i.e., participants who declared that COVID-19 infection had a negative impact on their physical activity), like another finding, in which patient’s walking time was significantly reduced six months after the onset of persistent symptoms after COVID-19 infection.¹² It could also be due to the muscle mass in male bodies and the fact that males, on average, engage in more physical exercise than females. Another viewpoint is that females are more likely to babysit and care for their children’s schooling, which has unquestionably altered substantially and become a bigger burden during COVID-19 pandemic, owing to quarantine and social isolation.

COVID-19 infection had a greater influence on physical activity among respondents with respiratory disease, which could lead to a negative impact on patients’ physical activity and cause further difficulties. However, more research is needed to confirm this link. Most people become sedentary as a result of the shift in lifestyle and the transformation of work and education to teleworking and tele-education. Impacts of COVID-19 was thoroughly documented in literature both locally and globally.^11,12 Physical activity was found to be strongly affected by quarantine and course of disease in a systematic review of 15 publications.¹¹ Furthermore, the reduction in physical activity after COVID-19 has a severe impact on people’s mental health and could lead to a variety of psychiatric problems.¹³

During the COVID-19 pandemic, the prevalence of physical activity among participants was drastically reduced. Both active and inactive people became less active than they were before the lockdown.^14,15 In Saudi Arabia, a survey-based study with 2,255 participants found comparable results, with more than half of respondents reporting a drop-in physical activity.¹⁰ However, the current study found a more significant link between COVID-19 infection and persistent symptoms in diabetic patients than non-diabetic patients, and in hypertension patients than patients without hypertension, which is supported by another study that found a higher prevalence of comorbidities with DM (68.3%), and hypertension (42.6%) after COVID-19 infection.¹⁶ As a result, patients with diabetes and chronic hypertension should be cautious about the long-term effects of COVID-19 infection on physical activity and muscular soreness after recovery.

Conclusion

COVID-19 had impacts on respiration, muscle strength, and daily activities. After COVID-19 infection, muscle ache and headache persisted in higher proportions than the other symptoms. Capability of daily activities was correlated to gender, respiratory diseases, diabetes, and hypertension.

Data availability